Whether you are a hearing aid user, considering hearing aids, or the loved one of someone with hearing loss, it is important to be aware of what hearing aids can and cannot achieve. In other words, you must be educated about hearing aid limitations. First, we’ll look at how hearing loss is measured and when hearing aids are considered appropriate. Then we’ll cover how hearing aids work to address hearing loss, and finally, some recommendations if hearing aids are not achieving the desired performance.

What Is Hearing Loss?

A proper hearing test, known as a diagnostic audiogram, is performed in a soundproof booth. Pure tones are presented to each ear individually at octave frequencies from 250-8000 Hz, which is the range of frequencies that captures the sounds of speech. These tones are presented in a way to determine the softest possible level you can hear at each frequency (pitch) in each ear. These thresholds are plotted on the audiogram to determine the degree of hearing loss, which can, and probably will, vary by frequency. For example, it is common to have a greater degree of hearing loss in higher frequencies than in lower frequencies. Your hearing should be relatively symmetrical between ears; if there is a significant difference between the ears, your audiologist will likely refer you for a medical evaluation with an ear, nose, and throat physician.

hearing loss chart
Image Credit: nationalhearingtest.org

Your audiologist will describe your hearing loss by degree and type. Sensorineural hearing loss indicates that the loss is at the level of the inner ear (cochlea). This type of hearing loss is typically associated with aging, noise exposure, or ototoxicity, among other causes. Conductive hearing loss occurs somewhere in the outer or middle ear. It can be permanent or fluctuating, depending on the cause. Causes of conductive hearing loss include a malformation of the outer or middle ear, fluid in the middle ear, excessive wax, or damage to the bones of the middle ear (ossicles). Hearing loss can also be described as “mixed,” meaning both conductive and sensorineural causes contribute to hearing loss.

Hearing aids can be recommended for all types and degrees of hearing loss, though both the type and loss may dictate the style of hearing aid that is most appropriate for your hearing loss. For example, a tiny completely-in-canal hearing aid is not going to be recommended for severe hearing loss because it simply cannot provide enough power or amplification to be beneficial. Hearing aid limitations this crucial are important for consumers to know before investing a large sum of money into a hearing aid device.

As part of a diagnostic hearing test, your audiologist will likely also test your discrimination ability for words. In this test, monosyllabic words are presented at a comfortable listening level based on your hearing loss. This is a general indicator of your discrimination ability once speech is loud enough, but it is not a perfect test. First, the stimuli are single words, so you do not have any context clues as you would in the course of normal speech. Second, the words are presented to each ear individually, so you do not have the benefit of binaural listening.

Finally, there are no visual cues. You would be surprised how much we all rely on lip reading and facial expressions, even with normal hearing. (Many people realized the true impact of this while wearing masks during COVID-19!) This test can be a rough indicator of future performance with hearing aids. If, when words are presented at a comfortable level, your discrimination abilities are good, this is a positive sign of future performance with hearing aids. If you perform poorly on this test, do not be overly concerned. The amplification provided by hearing aids is going to be customized to your hearing loss, not making everything equally loud.

How Do Hearing Aids Address Hearing Loss?

Digital hearing aids are programmed using the proprietary software of the hearing aid manufacturer with your specific hearing loss. Here is an example of what an audiogram might look like for someone with age-related hearing loss, also known as presbycusis.

hearing aid limitations
Image credit: tinnitusjournal.com

This patient has mild to moderately severe sensorineural hearing loss. Based on the audiogram, this patient is a good candidate for hearing aids. The audiologist would recommend hearing aids for both ears and probably in a style such as receiver-in-the-ear (RITE) that leaves the ears somewhat open because of the normal hearing thresholds present in the low frequencies. This will help to preserve comfort and natural sound quality. The hearing aids are going to provide amplification where the hearing loss is occurring, so greater degrees of amplification in the highest frequencies compared to the middle and low frequencies.

The hearing aids also have directional microphone technology, meaning they will attempt to focus on speech, which is likely in front of you, and reduce noise from the sides and behind. Depending on the technology level, the hearing aids may have multiple “scenes” they will switch into automatically based on the environment. Sometimes it can help to see these represented in polar plots, which demonstrate the focus of the microphones.

Below is an example from one hearing aid manufacturer (Phonak) using their trademarked terminology for different levels of directionality. 

hearing aid limitations
Image credit: Phonak.com

In the “Real ear sound” mode, the microphones are omnidirectional, meaning they are picking up sound equally from all around. This would be ideal in a quiet situation, such as at home, where you may be watching television but want to hear if your wife calls your name from the kitchen. In “UltraZoom,” the microphones are focused mainly in front and reduce sound from the back. This setting would work well in moderate noise where you want to focus on a few different speakers, such as a business meeting. In “StereoZoom” some of the noise from the sides is being attenuated in addition to noise from behind, so this would be ideal for a one-on-one conversation in a very noisy environment. These are simply the Phonak terms for these settings, but all hearing aid manufacturers have some version of adaptive directionality.

Many hearing aids will be constantly assessing the environment and automatically changing the directionality to provide the listener with the best settings to capture speech. Some patients like to “set and forget” their hearing aids and rely on the automaticity of the algorithm. In contrast, others prefer to have manual control of their hearing aids and may choose to have specific programs for different situations. This is something to discuss with your audiologist.

How Can I Make The Most Of My Hearing Aids?

While hearing aid technology is pretty incredible, it is not perfect. As mentioned, the goal of amplification is almost always to capture speech in the environment. Hearing aids make an assumption that you want to hear someone talking, or at a minimum, that you want to hear whatever is directly in front of you. It’s important to keep this in mind both as the hearing aid user and as a communication partner of a person with hearing aids. You will have the best chance of understanding someone when they are facing you, not only because of the hearing aid technology but also because of the added benefit of visual cues from the speaker. Do not expect hearing aids to make it possible to have a conversation from another room! It is the responsibility of both parties to make the listening environment ideal. Remember, too, that even people with normal hearing struggle in very noisy listening environments. So, set your expectations according to the situation.

Many hearing aids now have Bluetooth technology which will allow you to stream directly from your phone to your devices. This is amazing and certainly a large improvement over the awkward placement of the phone over your hearing aids or needing to rely on speaker phone. But, depending on the degree of hearing loss, the phone may continue to be a challenge. There are no visual cues over the phone, and competing noise on either end of the call can make the signal unclear. If possible, try to use technology to stream the phone call to both ears and position yourself in a quiet environment when using the phone.

Television can be a similar problem. You may be able to stream your television to your hearing aids like you can with phone calls, depending on the technology level. That said, there may be certain shows or situations where you choose to use closed captioning. I have normal hearing, and I use closed captioning if I’m watching a show where the actors have thick accents! 

There is an adjustment period when hearing aids are first fit, where they may seem uncomfortable or itchy, or you simply feel worn out after a day of wearing them. This is all normal. While hearing aids differ from glasses or contacts in many important ways, these symptoms of adjustment are very similar. If you have ever tried glasses or contacts, they may have been physically bothersome in the first few days, and then you hardly notice they are there. While putting on glasses will immediately correct your vision, the same cannot be said for hearing aids. The brain needs to adjust to the new sound quality, and this can take some time. The best way to get benefits from hearing aids is to wear them for all waking hours.

Is It Possible Hearing Aids Just Won’t Work For Me? Realistic Hearing Aid Limitations.

Hearing aids can provide a lot of improvement in daily life activities and communication, which can have a positive impact on personal, professional, and social life. If you are struggling with your hearing aids, consider the following:

  1. How long have you had the hearing aids? Have you followed the above recommendations to wear them for all waking hours? Have you communicated your concerns to your audiologist? 
  2. Do you have realistic expectations about your listening abilities in difficult situations? Have you advocated for yourself with friends, family, and coworkers to ask them to practice strategies to be good communication partners?
  3. Have you considered an assistive listening device? Suppose you are performing well with your hearing aids in most situations but continue to struggle in extreme noise or over-distance. In that case, you might consider a device that is paired with your hearing aids to provide added benefit in those specific situations.
  4. Have you gotten a second opinion on your hearing aids? If you aren’t satisfied with the service, it is possible to take your hearing aids to another setting and provider. You will be charged a fee for the time, and there is no guarantee that the audiologist will feel significant changes are necessary, but it is an option.
  5. Are there other factors or comorbid health conditions occurring? There is a strong link between hearing loss and dementia, and often the signs and symptoms could be attributed to either. If someone is struggling to understand even with hearing aids, it could be related to something neurological rather than audiological. If you suspect this might be a factor, consult your primary care physician.
  6. If you have moderately severe to profound hearing loss, it is possible that you are a better candidate for a cochlear implant than hearing aids. A cochlear implant involves an outpatient surgical procedure where an electrode array is placed inside the cochlea. A speech processor worn on the ear communicates with the internal device to transmit sound. A cochlear implant does not sound like hearing aids and does not sound like normal hearing but can restore access to sound for people who can no longer derive significant benefits from hearing aids. Talk to your provider if you think you might be a candidate for a cochlear implant. Candidacy is based on both degrees of hearing loss and performance with appropriately fit hearing aids.
erin edwards aud
Clinical Audiologist at Towson University | + posts

Erin Edwards received her Doctor of Audiology degree from Towson University in 2015 and her Ph.D. in Education and Leadership from Pacific University in 2022. She has worked with patients of all ages in a variety of settings and has a specific interest in cochlear implants, the relationship of hearing loss and dementia, and interdisciplinary healthcare.

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